Strengthen your network through automated appeals and grievances

Debbie Hill Debbie Hill
Sr. Director, UM Product Applications

Most health plans with Medicare Advantage, Medicaid and dual eligible populations know they need to be prepared to respond quickly to CMS audit requests – including a full account of appeals and grievances history, activity and status. After all, two of five Star Ratings factors can be tied to appeals and grievances processes, and noncompliance can also lead to steep penalties.


Effective, automated appeals and grievances management can help plans with government populations protect revenue by improving network quality. Easily identifying low-quality providers or services with high levels of grievances can provide insight on how or why certain claims were denied, as well as which providers or services in a network may be weak links – all offering opportunities to improve network strength.


Consider the fact that plans with a Star Rating of 3 lose an average 14.8% of their customers annually. For a plan with 150,000 members, that means more than 22,000 lost customers each year. At an average customer acquisition cost of $1,500 per member, the reacquisition cost comes to nearly $35 million.


By effectively automating the appeals and grievances process, health plans with government populations can do more than ensure timely regulatory compliance to avoid penalties. They can also save labor costs, lower the cost of disenrollment and get the visibility they need into network performance.


In addition, the right appeals and grievances application can align benefit guidelines with system applications. Knowing where an appeal stands at any moment — and having easy access to the history behind it — can help:

  • Ensure members with an open appeal aren’t referred again to the same provider
  • Prioritize members for care interventions, and guide care aligned to their preferences
  • Understand which providers have the highest and lowest instances of appeals and grievances
  • Guide business practices, such as delivering a better user experience, offering relevant information to members when services are denied and showing why a service might need to be covered in the future
  • Strengthen collaboration between case managers, care teams and medical directors for improved member service


These factors, when aligned with care management and Utilization Management, can improve the patient experience and make it easy for health plans with government populations to zero in on opportunities to reduce disenrollment and associated new-customer acquisition costs. It all contributes to a stronger, more optimized network.

Manage appeals and grievances with confidence with Medecision.

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